Archived: Priory Avenue Surgery

Updated 5 April 2018

Priory Avenue Surgery provides primary medical services to the Caversham area of Reading from a two-storey converted dwelling, which has undergone several extensions over the last 10 years.

There are no onsite parking facilities and the local roads have available parking for restricted times. There is one parking space adjacent to the practice for patients with limited mobility. The consultation and treatment rooms are on both the ground and first floors with three waiting areas. The first floor can only be reached by a staircase, with no lift facility currently in place.

There are approximately 6,800 patients registered with the practice. The practice serves a population in an area of mainly average deprivation but with some pockets of low deprivation. The practice has a larger number of patients aged 30 to 49 than other practices nationally. The number of patients over the age of 65 is similar to the national average.

One Medicare Ltd registered as the provider of Priory Avenue Surgery in September 2016.

There are two whole time equivalent (WTE) GPs, 1 WTE advance nurse practitioner (ANP), 1 WTE practice nurse and 0.4 WTE health care assistant sessions every week. There were male and female GPs available. The practice has an Alternative Provider Medical Services (APMS) contract.

When the practice is closed, out-of-hours (OOH) GP cover is provided by the Westcall 111 service. Notices on the entrance door, in the patient leaflet and on the practice website clearly inform patients of how to contact the OOH service.

All services are provided from: 2 Priory Avenue, Caversham, Reading, Berkshire, RG4 7SF.

Updated 5 April 2018

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Priory Avenue Surgery on 26 January 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months.

On 2 June 2017 we carried out a focused inspection at Circuit Lane Surgery to determine whether the practice was meeting the conditions applied following the January inspection.

The outcome of this inspection was that three out of six conditions imposed were removed. The current conditions in place during this inspection were:

• The registered person must implement a sustainable system to ensure outstanding and future repeat prescription requests, medication reviews, clinical correspondence and paper medical records requiring summarisation are reviewed and actioned without delay, to ensure patients are protected from risk of harm, at Priory Avenue Surgery. The existing backlogs for repeat prescription requests, medication reviews, clinical correspondence must all be cleared by 1st March 2017.The summarisation of paper records must be completed by 15th March 2017.
• The registered provider must ensure adequate capability, resource and capacity of all staffing groups in order to deliver a safe service. This includes providing adequate clinical staffing and appointments at Priory Avenue Surgery at all times to protect the health and welfare of patients .
• Effective and sustainable clinical governance systems and process must be implemented by 15th March 2017 at Priory Avenue Surgery. This is to ensure that all patients are able to access timely, appropriate and safe care; the systems and processes implemented protect patient safety and enable compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Both reports from the January 2017 and June 2017 inspections can be found by selecting the ‘all reports’ link for Priory Avenue Surgery on our website at www.cqc.org.uk. The practice has been managed by One Medicare Limited since September 2016 and they are registered to provide the services and this practice.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 10 October 2017. Overall the practice is now rated as requires improvement.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Our key findings were as follows:

• There was a system in place for reporting and recording significant events. However, this did not include a means of identifying patients involved in the event.
• The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse. However, we found staff had acted as chaperones without the appropriate knowledge of how to undertake this appropriately.
• The practice did not maintain appropriate standards of cleanliness and hygiene. We observed some areas of the treatment room and clinical rooms and the non-clinical areas on the ground floor of the premises to be dirty with a thick layer of dust. There was no cleaning schedule in place on the day of inspection.
• We reviewed five personnel files and found appropriate recruitment checks had been undertaken prior to employment.
• The practice had adequate arrangements in place to respond to emergencies and major incidents.
• The practice assessed needs and delivered care in line with relevant and current evidence based guidance and standards.
• The practice used the information collected for the Quality and Outcomes Framework (QOF) and performance against national screening programmes to monitor outcomes for patients. (QOF is a system intended to improve the quality of general practice and reward good practice). The most recent data from 2016/17 showed positive performance within the current QOF year (ending in March 2017).
• The practice had a clear and safe procedure for medicine reviews.
• Staff had the skills, knowledge and experience to deliver effective care and treatment. The systems for supervision of clinical staff did not ensure that new team members always felt supported in their role.
• The information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way through the practice’s patient record system and their intranet system.
• Staff sought patients’ consent to care and treatment in line with legislation and guidance. Although further understanding of the Mental Capacity Act 2005 was needed.
• We observed members of staff were courteous and helpful to patients and treated them with dignity and respect.
• Results from the national GP patient survey were mixed. The practice was below average for its satisfaction scores on consultations with GPs and nurses.
• Friends and family test results showed that patient satisfaction had increased since January 2017 then decreased in September 2017.
• Patients told us they felt involved in decision making about the care and treatment they received.
• The practice had an effective system in place for handling complaints and concerns.
• The provider’s vision to deliver high quality care and promote good outcomes for patients but this was not always supported by effective leadership and governance processes.
• There were arrangements for identifying, recording and managing risks within the practice; however, some risks were not identified.
• Clinical meetings were not consistently carried out and documented.
• Practice specific policies were implemented and were available to all staff. Although not all policies were followed, such as the chaperone policy.
• The practice had used most of their resources since the inspection in January addressing the areas of high risk and the clinical and administrative backlog. This had resulted in little opportunity for innovation or service development. There was also minimal evidence of learning and reflective practice.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

This service was placed in special measures in January 2017. Insufficient improvements have been made such that there remains a rating of inadequate for well-led. Therefore the service will remain in special measures. The service will be kept under review and if needed could be escalated to urgent enforcement action. Another inspection will be conducted within six months, and if there is not enough improvement we may move to close the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 10 January 2018

The provider was rated as requires improvement for the care of people with long-term conditions. The provider was rated as requires improvement for safety, effective, caring, responsive and inadequate for well-led services. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• Patient correspondence from external providers, such as hospital and paramedics, was with in a timely way.
• Patients reported improvements in issuing repeat prescriptions.
• The practice employed a pharmacist to assist with the health and medicines reviews of patients with long term conditions. For patients on less than four medicines 48% had an up to date medication review. For patients on four or more medicines 75% had an up to date medicine review.
• Data for diabetes related indicators showed achievement of 100% for 2016/2017.
• Longer appointments and home visits were available when needed.
• For those patients with the most complex needs, the practice worked with relevant health and care professionals to deliver a multidisciplinary package of care. However, patients felt that there was a lack of continuity of care which impacted on the management of their health needs.
• Unverified data for chronic obstructive pulmonary disease (COPD, a condition which causes breathing difficulties) indicators showed the practice had achieved 92% of patient annual reviews.

Updated 10 January 2018

The provider was rated as requires improvement for the care of families, children and young people. The provider was rated as requires improvement for safety, effective, caring, responsive and inadequate for well-led services. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances.
• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals.
• The practice’s unverified uptake for the cervical screening programme was 100%, which was above the expected achievement of 80%.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• We saw positive examples of joint working with midwives, health visitors and school nurses.

Updated 10 January 2018

The practice is rated as requires improvement for the care of older people. The provider was rated as requires improvement for safety, effective, caring, responsive and inadequate for well-led services. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• There was a system to prioritise older patients for appointments.

• The practice offered home visits and urgent appointments for those with enhanced needs.
• We saw hospital admissions, letters from specialists and paramedic correspondence was now acted on promptly which reduced the risks for this population group.
• The practice identified older patients and coordinated the multi-disciplinary team (MDT) for the planning and delivery of palliative care for patients approaching the end of life.
• We saw unplanned hospital admissions and re-admissions for the over 75’s were regularly reviewed and improvements made.
• Data showed that outcomes for patients for conditions commonly found in older people were within the target range. For example, 100% of patients diagnosed with dementia had their care reviewed in the last 12 months.

Updated 10 January 2018

The provider was rated as requires improvement for the care of working age people (including those recently retired and students). The provider was rated as requires improvement for safety, effective, caring, responsive and inadequate for well-led services. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• The surgery offered extended late appointments every Tuesday and Wednesday until 7pm and on Saturday mornings.
• The practice was proactive in offering online services for repeat prescriptions as well as a range of health promotion and screening that reflects the needs for this age group.

Updated 10 January 2018

The provider was rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). The provider was rated as requires improvement for safety, effective, caring, responsive and inadequate for well-led services. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• Data showed 92% of patients diagnosed with a severe mental health issue had a comprehensive agreed care plan in place.
• Data showed 100% of patients diagnosed with dementia had a comprehensive agreed care plan in place.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• The practice carried out advance care planning for patients living with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• Staff had a good understanding of how to support patients with mental health needs and those living with dementia.

Updated 10 January 2018

The provider was rated as requires improvement for the care of people whose circumstances may make them vulnerable. The provider was rated as requires improvement for safety, effective, caring, responsive and inadequate for well-led services. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice.

• The practice offered longer appointments for patients with a learning disability.
• Practice staff were trained to recognise signs of abuse within their vulnerable patients.
• GPs worked within a multi-disciplinary team to ensure the best outcomes for vulnerable patients. The practice worked with other health care professionals in the case management of vulnerable patients.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.